Pivoting school health and nutrition programmes during COVID-19 in low- and middle-income countries: A scoping review

Background Preventive and promotive interventions delivered by schools can support a healthy lifestyle, positive development, and well-being in children and adolescents. The coronavirus disease 2019 (COVID-19) pandemic presented unique challenges to school health and nutrition programmes due to closures and mobility restrictions. Methods We conducted a scoping review to examine how school health and nutrition programmes pivoted during the COVID-19 pandemic, and to provide summative guidance to stakeholders in strategic immediate and long-term response efforts. We searched MEDLINE, Embase, PsycINFO, and grey literature sources for primary (observational, intervention, and programme evaluations) and secondary (reviews, best practices, and recommendations) studies conducted in low- and middle-income countries from January 2020 to June 2023. Programmes that originated in schools, which included children and adolescents (5–19.9 years) were eligible. Results We included 23 studies in this review. They varied in their adaptation strategy and key programmatic focus, including access to school meals (n = 8), health services, such as immunisations, eye health, and water, sanitation, and hygiene-related activities (n = 4), physical activity curriculum and exercise training (n = 3), mental health counselling and curriculum (n = 3), or were multi-component in nature (n = 5). While school meals, physical activity, and mental health programmes were adapted by out-of-school administration (either in the community, households, or virtually), all health services were suspended indefinitely. Importantly, there was an overwhelming lack of quantitative data regarding modified programme coverage, utilisation, and the impact on children and adolescent health and nutrition. Conclusions We found limited evidence of successful adaptation of school health and nutrition programme implementation during the pandemic, especially from Asia and Africa. While the adoption of the World Health Organization health-promoting school global standards and indicators is necessary at the national and school level, future research must prioritise the development of a school-based comprehensive monitoring and evaluation framework to track key indicators related to both health and nutrition of school-aged children and adolescents.

, we selected studies based on population, concept, context, and sources of evidence.Studies were eligible if they were published after December 2019, where the primary exposure was severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).Classification of LMICs was conducted according to the World Bank's 2022 fiscal year country income classification.Studies that were multi-country and included both a high-income and a LMIC were required to report disaggregated data by country for inclusion (Table 1).

Concept
Studies that investigated the adaptation of school health and nutrition policies and programs due to the COVID-19 pandemic.This includes adaptation strategies and components, coverage and utilisation, impact on diets, food security, anthropometry, diet-related health outcomes, and barriers and facilitators to adaptation.

Context
Low-and middle-income countries as defined by World Bank 2022 Conducted in schools, virtually, in community settings, or in homes

Sources of evidence
Observational (i.e.cross-sectional) Intervention (i.e.randomised controlled trials, quasi-experimental studies) Programme evaluations Reviews Best practices and recommendations

Other
No language restrictions Published between January 2020 and June 2023 Studies conducted in schools, with children and adolescents (5-19.9years) were eligible for inclusion.We used our primary outcomes of interest as eligibility criteria for including studies (i.e.we excluded a study if it did not report any of the primary outcomes).However, we did not exclude studies based on how that outcome was reported (i.e. that an effect size is not estimatable, although the outcome was clearly measured).We excluded animal studies, conference abstracts, and letters/comments, as well as those that included participants outside of the age range and did not report disaggregated data.
Studies that examined how existing school health and nutrition policies, guidelines, and programme characteristics pivoted during COVID-19 were eligible for inclusion.This included the provision of meals (breakfast, lunch, or dinner) or snacks consumed at school (in-school feeding), as well as foods distributed to the family and consumed outside of the school setting (take-home rations).We also included studies that examined food stamps or food vouchers distributed at school for the participants to access foods (in the market or food banks).Furthermore, we included both preventive and management-based health and nutrition interventions targeted at school-aged children and adolescents in LMICs which were implemented within schools before COVID-19 and adapted due to the pandemic.We considered any policy, regulation, or guideline that affected the school health and nutrition environment, including interventions that attempt to influence food availability, accessibility, policy, pricing, and promotion as an intervention.

Data synthesis
GD, EK, and KJ extracted data independently using a standardised form to characterise and analyse the outcome data.The charted data were analysed descriptively, using tabulations or graphs where appropriate, to present a synthesis of key findings according to the scoping review objectives.The narrative synthesis of the extracted data was based on several characteristics, including geographic location of primary studies, schooling level, key components that were pivoted, and the duration of interventions.We followed the PRISMA-ScR guidelines in reporting our findings (Table S3 in the Online Supplementary Document).

RESULTS
We identified 15 824 records in our search, of which we removed 213 through deduplication, leaving 15 611 for screening.Only 228 studies were eligible for the full-text screening stage, during which we excluded 205 studies, leaving 23 for inclusion in this review (Figure 1 and Table 2).

Multi-component programmes
The responses from multi-component programmes were found to be entirely dependent on programme type.In two studies which looked at providing nutrition and health services in South Africa and Ethiopia, respective in-school nutrition programmes continued to provide meals and supplementation during lockdowns, while their health services which comprised of sexual and reproductive health education, deworming treatments, and immunisation services were suspended indefinitely [14,18].A programme in the Ogoni area of Rivers State, Nigeria continued to operate in six schools with physical distancing by serving food to children spread across multiple classrooms, rather than a single one as was done previously.The feasibility of this was 2-fold: additional classrooms were available due to the suspension of in-person classes, while the programme only provided food to the poorest students from each school [18].Similar to these studies, another multi-component programme for psychological counselling and outdoor exercise in China opted to continue these programmes in school to support children during the pandemic.In turn, the study found that the combination of these components led to significantly improved scores in psychological resilience among the experimental group (P < 0.05), although no significant differences were identified for changes in anxiety, depression, and sleep quality scores [33].
In contrast, other multi-component programmes were found to shift entirely to virtual adaptations (n = 1) or administration outside of schools (n = 1).The 'Promoting Health Literacy in Schools Plus Study' nutrition and physical activity intervention implemented in eight private schools across New Delhi was switched entirely to a virtual platform to promote healthy lifestyles among students, which included components such as the importance of a healthy diet; physical activity; prevention and management of NCDs, especially diabetes and obesity; and the interlinkages between NCDs and COVID-19 [29].In comparison, psychosocial and health services screenings for students were conducted at home by social workers and nurses in South Africa as a novel government-led health promotion strategy in response to school closures [26].

School food and nutrition programmes
Of all programme types, SFPs were found to have the most varied responses to the COVID-19 pandemic.Three studies noted programmes were entirely suspended following school closures in Nigeria, Ethiopia, and Indonesia [13,16,19,32].The Nigerian National Home-Grown School Feeding Program, which provided one meal per day to over nine million children enrolled in government-owned primary schools (grades 1-3, ages 6-9 years), was suspended following school closures in March 2020 [13].Similarly, the Addis Ababa city SFP, which previously provided two meals per day to approximately 360 000 students attending government primary schools, was halted indefinitely on 16 March 2020 following the closure of all schools in Ethiopia, as reported by a paper published in July 2021.It is worth noting that the decision to suspend school feeding was not due to financial constraints, as the programme already had an allocated budget per child per day; rather, the funds were to remain unused until a proven intervention mechanism was established as per the current finance regulation [16].
Moreover, school closures in Indonesia resulted in the closure of 144 school canteens among 147 surveyed public and private schools, which were still shut as of February 2021.Of these schools, 85% felt that they would be ready to re-open their canteens once provided with information regarding government regulations or guidelines for reopening, despite no such documents having been prepared at the time of this study.Readiness to re-open was 4.5 times higher among schools that owned their canteen compared to schools that did not have ownership (adjusted odds ratio (aOR) = 4.5; 95% confidence interval (CI) = 1.1, 17.9), which may be explained by greater managerial authority and control by schools with ownership [19].The Midday Meal Scheme in India was the only programme identified that explicitly noted physical distancing measures were planned and implemented in order to continue the SFP after school re-openings [32].
To compensate for programme suspensions, four studies began distributing meals and/or food kits to the homes of students and their families [15,23,25,30].Thirteen countries implemented this model, most of which were located in Latin America (n = 11).Food kits, which contained foods to be prepared/cooked at home, were distributed in Argentina (specifically Buenos Aires), Brazil, Chile, Columbia, Costa Rica, Ecuador, Guatemala, Mexico, and Peru [15,23,30].Prepared meals were provided to students in Argentina (specifically Buenos Aires), Brazil, Colombia, Puerto Rico, Thailand, and Uruguay, either instead of or in addition to food kits [15,25].Rations of specific food products were distributed in two countries.Shelf-stable milk was distributed in Thailand and grains in Uttar Pradesh State, India [25].
The frequency of distribution of food kits and meals varied by country, as well as by district and/or state within countries.In countries that specified frequency, meals were distributed more frequently than food kits, with Uruguay and Puerto Rico both providing daily meals.Food kits were distributed as frequently as every 15 days up to every month [15].Challenges regarding the delivery of food kits and meals to students were identified as a barrier by several countries.These problems impacted food content due to refrigeration requirements and delayed distribution frequencies in some cases [15,23].For example, the first monthly deliveries of food kits in the municipality of Campos dos Goytacazes, Brazil took approximately two to three weeks to complete [23].In most cases, food kits and meals were expected to be picked up by students or their family members from schools or community centres.Exceptions to this included food kits that were delivered directly to students' homes, such as in Thailand, while meals were served within schools in Uruguay despite school closures [15,25].Moreover, seven countries reported reduced nutritional quality of food kits compared to pre-pandemic SFPs, which was attributed to insufficient financial resources and quality assurance and safety constraints of perishable foods [15,23].Fresh products were limited and were often replaced by processed foods.Conversely, food kits in Peru contained greater diversity in the types of foods compared to those provided pre-pandemic.This was accomplished by distributing kits with foods to be prepared at home, rather than supplying processed meals as was done previously [15].
Alternatively, three papers identified several South American countries that provided financial compensation to students and their families to alleviate the burden of missed school meals [15,16,23].Rural areas of Uruguay provided food vouchers to families upon request, which were redeemable at local supermarkets and held a value equivalent to the daily cost of a school lunch.Some areas of Colombia provided monthly food vouchers, which were valued at approximately USD 14 and could only be used to purchase certain foods [15].While most areas of Brazil supplied meals and/or food kits, the municipality of Macaé implemented cash transfers, as this method circumvented many logistical issues associated with the distribution of food.While the Brazilian National School Feeding Program's pre-pandemic guidelines would have prevented this, Macaé passed a municipal law in late March 2020 that authorized the payment of 200 BRL per month ( ~ 20% of the national minimum monthly wage, USD 35.03) to all students enrolled in public municipal schools.Implementation of cash transfers began in April 2020 and by August 2020; 99% of beneficiaries had received financial aid via one of three delivery models.These delivery models included: transfer of funds directly into the chequing accounts of students' guardians; preloaded cards available for pickup at schools; and withdrawal of funds from a local bank.Despite high coverage, the authors noted that cash transfers may not be cost-effective long-term due to higher costs spent per food item compared to buying food in bulk when purchased by the municipality.Furthermore, similar to food kits, cash transfers do not guarantee that foods purchased are consumed by students, nor do they guarantee food and/or diet quality [23].

Health services
The majority of the studies (n = 3) which investigated the impact on in-school health services found that programmes were stopped indefinitely.In Nigeria, this disruption impacted over 1450 students residing in five rural villages across the Rivers State and left them vulnerable to infectious diseases, such as measles, polio, tetanus, typhoid, and yellow fever after annual immunisations were halted [31].Only one programme conducted in Nigeria looked to retroactively correct disruptions in human papilloma virus (HPV) vaccination among girls between nine to 14 years old.Although these girls were intended to receive their second dose in August 2020 -six months after their initial dose -the study team was unable to return to the community until November 2020 due to school closures, which extended their vaccination schedules and left five girls lost to follow-up presumably vulnerable to HPV [17].

Physical activity
Included programmes exclusive to physical activity (n = 3) were all found to shift towards virtual adaptations.Policy-level changes were specifically implemented by the Chinese government to include virtual recess and physical activity in online schooling and education curricula.For instance, a randomised controlled trial conducted across 12 secondary schools from the Duanzhou District in Zhaoqing City aimed to investigate whether online adaptations to physical activity initiatives were able to reduce children's anxiety, eye strain, and sleep disturbances.Students were provided with a 10-minute virtual physical activity and eye relaxation breaks in addition to 15-minute recesses four times a day.Reminders were sent through short message service prompts and exercise activities were conducted through a live-streaming application for students to remain connected with their peers.Results from this trial indicated a significant reduction in children's anxiety from baseline between intervention and control groups (x -= −0.36; 95% CI = −0.63,−0.08, P = 0.02) and eye strain (x -= −0.15; 95% CI = −0.26,−0.03, P = 0.02) scores post-intervention [35].Likewise, in Brazil, physical education was provided via Google Classroom to promote physical exercises, body movement practices, sports practice, dance, games, and physical activity at home, which were found to have improved students' Self-Perceived Physical Fitness scores regarding self-perceptions of physical fitness in strength, flexibility, body weight, general fitness, and cardiorespiratory fitness [22].

Mental health
All mental health programmes exclusively (n = 3) were found to adapt virtually.The School Mental Health Program in rural Pakistan used task-shifting to aid mental illness prevention and mental health promotion by establishing teacher-led assessment and support systems, as well as creating access to broader referral networks if needed.However, the training of teachers and student support activities were conducted through virtual chats and calls to meet the critical mental health needs of students during the pandemic.To overcome technological and financial barriers to accessing these online resources, the school curriculum was also broadcasted through televisions [20].Likewise, five private schools in Beirut, Lebanon also adopted virtual counselling to replace traditional in-school counselling available to students.This programme had several challenges in supporting students through a virtual interface as opposed to in-school discussions that allowed for both formal and informal interactions.Counsellors mentioned virtual modalities having a steep learning curve which prompted more demanding work schedules given they were expected to be accessible for longer work hours.However, students were found to be less comfortable seeking guidance while sharing personal stories within their households, which made it difficult for counsellors to provide adequate and timely support [21].

DISCUSSION
In this scoping review, we examined the available evidence on the adaptations of school health and nutrition programmes, including school meal programmes, health services, and physical activity education in LMICs.We found limited evidence of successful retooling of programme implementation during the pandemicrelated mobility restrictions, especially from Asia and Africa.Our findings highlight the barriers school health and nutrition programmes experiences, not only in continued service provision, but also in ensuring the quality of those services once the adaptations were in place.
The most varied adaptations were in the delivery of SFPs, including their indefinite suspension or provision of alternative forms of aid, such as cash transfers.However, based on the included studies, there was an overwhelming lack of quantitative data regarding modified programme coverage, use and the impact on children, and adolescent health and nutrition.This may be attributed to limited publicly available data on national or subnational emergency responses, including by the World Food Programme and other non-governmental organisations, resources largely directed to health systems during the pandemic, and a lack of an internationally recognised framework of indicators to monitor and evaluate school health and nutrition programmes [36].Three studies explicitly noted the impact of disruptions to SFPs on food security in Ethiopia, Nigeria, and Brazil [13,16,30].These studies found that the suspension of the programme decreased food security and negatively impacted students' health, whereby some students reported having skipped meals, receiving reduced portion sizes, and consuming poor-quality foods.It was also noted that the suspension of school-provided meals, in combination with parental job loss, may have reduced protections against child labour, as the need to generate income for the family becomes greater [15].Our results are corroborated by a recent study by Ferrero et al., which gathered data from 183 programmes in 139 countries on largescale school meal programme operations managed by countries or non-governmental organisations during COVID-19.Their results suggest that, in addition to food provisions, complementary health services significantly decreased in response to the pandemic.This not only heightens food insecurity already pervasive in low-resource settings, but also disrupts their access to health care [37].
Comprehensive school health and nutrition programmes that are tailored to country priorities and needs are an equitable and cost-effective way to improve access to health and nutrition services and play a critical role in addressing the global learning crisis [38].Globally, 90% of countries have implemented some form of school health and nutrition programmes at scale.For example, more than 100 countries have school-based vaccination programmes, more than 450 million school-age children are dewormed every year in schools in LMICs, and almost every country includes education for health and well-being in its curriculum [38].School feeding programmes offer healthy meals, which are critical for nutritionally vulnerable school-aged children and adolescents.These programmes are particularly cost-effective because they deliver returns across mul-tiple sectors, including education, health, agriculture, and social protection, with US 9 in returns for every US 1 invested [39].Psychosocial programmes that address anxiety, depression, and suicide can provide an average return on investment across all countries of US 21.5 for every US 1 invested over 80 years [40].
Importantly, the COVID-19 pandemic has provided a unique opportunity to evaluate current gaps in programming and build back better [41].In 2021, governments united to acknowledge the necessity for an innovative approach to supporting school-aged children and adolescents while simultaneously promoting sustainable dietary habits and food systems.This culmination led to the introduction of a global School Meals Coalition at the United Nations Food System Summit in October 2021 [9].Currently, this coalition consists of 76 member states, collectively responsible for 58% of the world's student population, representing diverse geographical regions and encompassing high, middle, and low-income nations [9].The creation of financially independent, intersectoral working groups may be useful to provide guidelines on best practices for service delivery during school closures to ensure effective usage of finite resources [15].
While globally, most countries have policies related to school health and nutrition [9], in order to be resilient to emergencies and crises, health and nutrition adaptation policies must be institutionalised in education systems by establishing dedicated committees tasked with developing and implementing such policies at national, subnational, and local levels.According to joint guidance provided by the Food and Agriculture Organization, World Food Programme, and UNICEF, countries should establish a multisectoral emergency task force that is responsible for school feeding, either as part of a broader response to the food and nutrition situation or independently, to rapidly assess the situation and provide options of feasible responses is recommended [42].Of the 11 identified Latin American countries in this review, there was no mention of SFPs in the emergency declarations of any country, except for a general reference to feeding made by Peru.Due to lack of established guidelines, many countries struggled early on to determine the most effective strategies to continue providing meals to students.In Chile, Colombia, Ecuador, Guatemala, and Brazil, SFPs are protected by national law, which enabled mobilisation of resources, helped to maintain nutritional standards, and provided political support for the continuation of modified SFPs during the pandemic [15].For example, Brazilian National School Nourishment Program guidelines require that municipalities continue to ensure students' right to adequate food even in times of crisis [23,30].However, legislation and guidelines in several countries required modification to make them more suited for the changing needs of programmes during the pandemic [15].Before the pandemic, the guidelines stipulated that meals could only be offered to students at schools.This changed on 7 April 2020, when the Ministry of Education passed a federal law (Federal Law No.13 987) that allowed municipalities to distribute food directly to students or their parents/ guardians during an emergency [23].Changes to SFP policies were not as flexible in other countries, which was also identified as a barrier.Notably, legislation in Peru (D.Leg.No. 1472) restricted schools' financial autonomy needed to modify SFPs [15].
Besides policies, school infrastructure and resources should align with international standards and guidelines by ensuring proper ventilation, WASH facilities, barrier fencing for traffic control, and social distancing [31].The pandemic has already prompted the use of virtual platforms, which has been shown to provide some sustainability to school physical and mental health programmes [35].Investing in similar technological resources to maintain access to health services in other contexts may be valuable to ensuring children's health and well-being.Alternatively, school health programmes that may require in-person consultations, such as food provisions, immunisations, and treatments may benefit from collaborating with existing community facilities.For instance, providing school food provisions through food banks and other community safety net programmes has been encouraged to curb the massive impact of lost meals amongst children in Ethiopia [16].Conducting immunisations and treatments within local clinics and primary care facilities may be a similar adaptation worth exploring to ensure children and their families are still able to access vital health services during emergency crises that mandate school closures.
Although this was an exploratory review, it highlights the lack of evidence on school health and nutrition programming during a global pandemic.School health and nutrition programmes should be monitored under normal circumstances and during times of crisis in order to accurately measure the success of modified programmes and to support evidence-based policy and programme development.While the adoption of the WHO global standards and indicators is necessary at the national and school level, future research must prioritise the development of comprehensive school monitoring and evaluation framework to track key indicators related to both the health and nutrition of school-aged children and adolescents.Programme monitoring should be integrated into existing school-based data sources and should promote the flow of information from the local to national levels [32].The collection of and access to sex-and gender-disaggregated data has also been limited, which has made it difficult to determine the gendered impacts of COVID-19 and, in turn, the disruptions in school health and nutrition programmes.Therefore, ensuring the inclusion of gender-specific data into existing monitoring and evaluation systems is crucial to informing the development of future policies and programmes [43].

CONCLUSIONS
Schools across the globe experienced prolonged and intermittent closures during the COVID-19 pandemic, with the most recent of these occurring as recently as March 2022.The adverse effects of these school closures range from loss in learning, premature school dropouts (especially for girls), as well as poorer mental health and social development of school-aged children, potentially translating into long-term adverse outcomes into adulthood.The recommendations highlighted in our review apply to not only pre-existing programmes aiming to build back better, and gain the ground lost over the last three years, but also provide a framework to be used in times of future crises, whether it be an infectious diseases epidemic or pandemic, conflict or natural disaster.If we are to learn one thing from the COVID-19 pandemic and its impact on the health and well-being of children and adolescents, it is that continued provision of educational, health and nutrition services should be of paramount concern for stakeholders and policymakers across all sectors and levels of governments.

Table 2 . Characteristics of included studies Author (year) LMIC setting Date Study design Population affected Type of programme Impact due to COVID-19
study Students (6-13 y old) Physical activity Virtual Adaptation -physical education classes were shifted to online platforms using Google Classroom.www.jogh.org• doi: 10.

7189/jogh.14.05006 Author (year) LMIC setting Date Study design Population affected Type of programme Impact due to COVID-19
SFP -school food programme, HPV -human papilloma virus, y -years